Do behavioral drivers matter for healthcare decision-making during crises? A study of low-income women in El Salvador during the COVID-19 pandemic

Abstract Understanding health-seeking behaviors and their drivers is key for governments to manage health policies. A growing body of research explores the role of cognitive biases and heuristics in health and care-seeking behaviors, but little is known about how a context of heightened anxiety and uncertainty might influence these behavioral drivers. This study analyzes the association between four behavioral predictors—internal locus of control, impatience, optimism bias, and aspirations—and healthcare decisions among low-income women in El Salvador, controlling for other factors. We find positive associations between internal locus of control and preventive health behaviors during the COVID-19 pandemic. For instance, a one standard deviation increase in locus of control is associated with a 10% increase in an index measuring the use of masks, distancing, hand washing, and vaccination. Locus of control was also associated with women’s use of preventive health services (one standard deviation improves the likelihood of having a hypertension test in the last six months by 5.8 percentage points). In a sub-sample of mothers, we find significant relationships between the four behavioral drivers and the decisions the mothers make for their children. However, we find these associations are less robust compared to the decisions they make for themselves. Some associations were stronger during the pandemic, suggesting that feelings of uncertainty and stress could amplify behavioral drivers’ influence on health-related behaviors. This novel finding is relevant for designing policy responses for future shocks. JEL Codes I12, D10, D91, I30. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-024-19039-y.

Notes: Columns (1) and (4) report the mean of the behavioral driver if the demographic variable is equal to 0; and Columns (2) and ( 5) report the mean when the demographic variable is equal to 1. Columns (3) and ( 6) report Pearson's chi squared test of the difference.The behavioral explanatory variables of interest are described as follows.Internal locus of control was measured on a scale from 1 to 5, where 5 is a high internal locus of control; impatience was measured on a scale from 1 to 32, being 32 with high impatience, its standardized version with mean 0 and standard deviation of 1 is reported; optimism bias was measured on a scale from 0 to 10 being scores higher than five more optimistic; finally, educational aspirations were measured with a binary variable that takes a value of 1 if the mother aspires their children to have an educational career such as medical doctors, lawyers, engineers, architects, or educators.

Variables
(1) (2) (3) (4) (1) Health-related optimism bias 1.000 (2) Internal locus of control 0.039 1.000 (3) Present bias 0.005 -0.061 1.000 (4) Educational aspiration for offspring 0.068 0.117 * 0.009 1.000  6) present the results for outcomes reported by women in the survey.Columns (7) to (8) presents the results for children related outcomes.Since only women with children report these outcomes the sample size is smaller.The model for women outcomes that includes controls (columns 2, 4, and 6) follows equation (1) in section four and includes the women, household, and facility controls listed in Table 1, as well as municipality fixed effects.The model for children in the last column follows the same equation but includes the child level controls from Table 1 as well.The behavioral explanatory variables of interest are described as follows.Impatience is the standardized measure of the present bias index; internal locus of control is the standardized measure of the adapted locus of control index; optimism bias is the standardized measure of the general optimism bias Index; and educational aspirations is the standardized measure of the educational aspirations Index.Notes: * p < 0.1, ** p < 0.05, *** p < 0.01.OLS estimations with robust standard errors clustered at the facility level in parentheses.The model in each panel is that of the outcome of interest against just one behavioral explanatory variable at a time.
Columns (1) to (4) present the results for outcomes reported by women in the survey.Columns (5) to (10) presents the results for children related outcomes.Since only women with children report these outcomes the sample size is smaller.The model for women outcomes that includes controls (columns 2 and 4) follows equation (1) in section four and includes the women, household, and facility controls listed in Table 1, as well as municipality fixed effects.The model for children that includes controls (columns 6, 8, and 10) follows the same equation but includes the child level controls from Table 1 as well.The behavioral explanatory variables of interest are described as follows.Impatience is the standardized measure of the present bias index; internal locus of control is the standardized measure of the adapted locus of control index; optimism bias is the standardized measure of the general optimism bias Index; and educational aspirations is the standardized measure of the educational aspirations Index.9) present the results for outcomes reported by women in the survey.Columns (10) to (12) presents the results for children related outcomes.Since only women with children report these outcomes the sample size is smaller.OLS estimations with robust standard errors clustered at the facility level in parentheses.P-values are presented in square brackets.The first p-value refers to the one obtained using the standard errors clustered at the facility level and that is equivalent to one of Tables 6 and 7 in the article.Below that are p-values adjusted for multiple hypothesis testing using different methodologies.For multiple hypothesis testing in this table, we group together all outcomes obtained from women (columns 1 to 9) using the same specification as a family of outcomes, and we consider children COVID-related behaviors as a separate family.Since the latter is just one outcome, we present no multiple hypothesis testing adjustment for this.Anderson (2008) refers to the q-value adjusted for false discovery rates; this is the least conservative adjustment.Romano-Wolf (2005) and List et al ( 2019) are both p-value adjustments for familywise error rates and both tend to be more conservative as they tend to control for reducing the likelihood of false positives.Oster coefficient bounds, refer to methods described in Oster (2016) to measure the stability of the coefficient of interest to the inclusion of unobserved variables, subject to some key assumptions regarding how much the R-squared will increase with the inclusion of such unobserved variables (Rmax) and the proportionality of the unobservable relative to the observable variables ().For this bound we use two scenarios presented in Oster (2019), one with Rmax=1.3*R 2 and =1, which is the most widely used in the literature and a more conservative one with Rmax=2.2*R 2 and =1.The result presented in the table is the bound to the coefficient of interest based on these assumptions if unobserved variables were included in the equation.Columns (1), ( 4), (7), and (10) present our preferred specification which we include in Tables 6 and 7 in the document.Columns (2), ( 5), ( 8) and ( 11) present the model without any controls.Columns (3), ( 6), ( 9) and ( 12) add facility fixed effects to the specification in addition to the individual and household controls.No facility controls or municipality fixed effects are included in this specification since they are collinear with the facility fixed effects.Section 4 in the paper describes the main specification and Table 1 includes the list of controls.The behavioral explanatory variables of interest are described as follows.Impatience is the standardized measure of the present bias index; internal locus of control is the standardized measure of the adapted locus of control index; optimism bias is the standardized measure of the general optimism bias Index; and educational aspirations is the standardized measure of the educational aspirations Index.Notes: Columns (1) to ( 6) present the results for outcomes reported by women in the survey.Columns ( 7) to (15) presents the results for children related outcomes.Since only women with children report these outcomes the sample size is smaller.OLS estimations with robust standard errors clustered at the facility level in parentheses.P-values are presented in square brackets.The first p-value refers to the one obtained using the standard errors clustered at the facility level and that is equivalent to one of Tables 6 and 7 in the article.Below that are p-values adjusted for multiple hypothesis testing using different methodologies.For multiple hypothesis testing in this table, we group together all outcomes obtained from women (columns 1 to 6) using the same specification as a family of outcomes, and we consider children general health behaviors as a separate family.Anderson (2008) refers to the q-value adjusted for false discovery rates; this is the least conservative adjustment.Romano-Wolf (2005) and List et al (2019) are both p-value adjustments for familywise error rates and both tend to be more conservative as they tend to control for reducing the likelihood of false positives.Oster coefficient bounds, refer to methods described in Oster (2016) to measure the stability of the coefficient of interest to the inclusion of unobserved variables, subject to some key assumptions regarding how much the R-squared will increase with the inclusion of such unobserved variables (Rmax) and the proportionality of the unobservable relative to the observable variables ().
For this bound we use two scenarios presented in Oster (2019), one with Rmax=1.3*R 2 and =1, which is the most widely used in the literature and a more conservative one with Rmax=2.2*R 2 and =1.The result presented in the table is the bound to the coefficient of interest based on these assumptions if unobserved variables were included in the equation.Columns (1), ( 4), ( 7),( 10) and (13) present our preferred specification which we include in Tables 6 and 7 in the document.Columns (2), ( 5), ( 8), (11), and ( 14) present the model without any controls.Columns (3), ( 6), ( 9), (12), and (15) add facility fixed effects to the specification in addition to the individual and household controls.No facility controls or municipality fixed effects are included in this specification since they are collinear with the facility fixed effects.Section 4 in the paper describes the main specification and Table 1 includes the list of controls.The behavioral explanatory variables of interest are described as follows.Impatience is the standardized measure of the present bias index; internal locus of control is the standardized measure of the adapted locus of control index; optimism bias is the standardized measure of the general optimism bias Index; and educational aspirations is the standardized measure of the educational aspirations Index.

Figure A1. Decision tree for the impatience measure
Notes: Decision tree for the impatience measure based on Falk et al. ( 2022).The amounts were updated to a similar amount to USD in El Salvador using purchasing power parity.A. Refers to payment today, and B for payment in 12 months.The impatience measure is the reverse of score since the tree was originally used to measure patience.

Figure A2. Sensitivity of the results of behavioral predictors of COVID-19-related health behaviors to municipal outliers.
Notes: Each chart presents the coefficient of the behavioral predictors on our outcome of interest, which is presented on the title of each chart.The yellow diamond-shape presents the coefficient in a model with all 14 municipalities included.The dots represent the value of the coefficient of interest, excluding one of the 14 municipalities at a time.The green dots under over the value of 1 in the xaxis refer to our preferred specification which we include in Tables 6 and 7 in the document.The gray dots over the value of 2 in the x-axis, present the model without any controls.The purple dots over the value of 3 in the x-axis add facility fixed effects to the specification in addition to the individual and household controls.No facility controls or municipality fixed effects are included in this specification since they are collinear with the facility fixed effects.Section 4 in the paper describes the main specification and Table 1 includes the list of controls.The behavioral explanatory variables of interest are described as follows.Impatience is the standardized measure of the present bias index; internal locus of control is the standardized measure of the adapted locus of control index; optimism bias is the standardized measure of the general optimism bias Index; and educational aspirations is the standardized measure of the educational aspirations Index.

Figure A3. Sensitivity of the results of behavioral predictors of general health behaviors to municipal outliers.
Notes: Each chart presents the coefficient of the behavioral predictors on our outcome of interest, which is presented on the title of each chart.The yellow diamond-shape presents the coefficient in a model with all 14 municipalities included.The dots represent the value of the coefficient of interest, excluding one of the 14 municipalities at a time.The green dots under over the value of 1 in the xaxis refer to our preferred specification which we include in Tables 6 and 7 in the document.The gray dots over the value of 2 in the x-axis, present the model without any controls.The purple dots over the value of 3 in the x-axis add facility fixed effects to the specification in addition to the individual and household controls.No facility controls or municipality fixed effects are included in this specification since they are collinear with the facility fixed effects.Section 4 in the paper describes the main specification and Table 1 includes the list of controls.The behavioral explanatory variables of interest are described as follows.Impatience is the standardized measure of the present bias index; internal locus of control is the standardized measure of the adapted locus of control index; optimism bias is the standardized measure of the general optimism bias Index; and educational aspirations is the standardized measure of the educational aspirations Index.

Women avoided health care for herself or someone in the household for fear of COVID-19 Women followed COVID-19 non- pharmaceutical prevention measures Women got the COVID-19 vaccine or is willing to get it Mothers avoided health care for their children for fear of COVID-19 Panel A. Impatience only
p < 0.1, ** p < 0.05, *** p < 0.01.OLS estimations with robust standard errors clustered at the facility level in parentheses.The model in each panel is that of the outcome of interest against just one behavioral explanatory variable at a time.Columns (1) to ( *